From gold standard to platinum standard in BPH surgery: a perspective from a tertiary care center of the Indian subcontinent

INTRODUCTION

For last eight decades, transurethral resection of the prostate (TURP) has remained the mainstay of surgical treatment for BPH, due to the procedure’s excellent, well-documented and long- lasting treatment efficacy.¹ Nevertheless, the morbidity of the procedure, notably TURP-syndrome, bleeding and urethral stricture, remains significant at 11.1%, based on a prospective, multicentre study of 10,654 men.² BPH becomes an increasingly common phenomenon as men age. Patients with clinically bothersome LUTS suggestive of BPH not relieved with medical treatment benefit from transurethral resection/vaporization of prostate using various energy sources. Monopolar TURP has been the main form of treatment for many years in men with BPH and remains the gold standard against which other treatments are evaluated. Most patients opting for TURP experience a marked decrease in urinary symptom scores with substantial increase in maximal urinary flow rates. Complications associated with TURP have encouraged development of several alternative methods to remove adenomatous tissue using a variety of energy sources. During the past 2 decades, role of m-TURP has been challenged by the development of various other energy sources including laser and robotic approaches. Despite demographic changes towards advanced ageing along with increasing number of patient’s being non-compliant and unrelieved with medical therapy, the numbers of prostate surgeries have declined substantially in recent times.

Although TURP has persisted for decades, the current procedure differs significantly from that performed 30 years ago. There have been improvements in operative technique, instrument technology, and anaesthetic methods. TURP is now safer, with a much lower mortality rate reported, but the effect these changes have had on long-term outcomes is largely unknown.^3,4 Recent long-term studies which include TURP use the procedure as the control arm. Currently, the standard TURP technique recommends a complete resection of all adenomatous tissue; however, the duration of the operation and the amount of the tissue removed are directly associated with intraoperative and early postoperative complications. The aim of this article is to review the role of m-TURP in contemporary BPH management. In doing so, we discuss (1) diagnostic work-up, (2) indication, (3) technical aspects, (4) short and long-term complication, and (5) clinical outcome.

METHODS

This retrospective study included 275 patients with bothersome LUTS and histologically confirmed BPH, who underwent m-TURP at Dept. of Urology and Renal Transplantation between July 2010 and July 2015 and were in follow up for at least 24 months in the Urology OPD. The most frequent indication (50–60%) for TURP is LUTS refractory to medical therapy. The following BPH complications are considered strong indications for TURP [2]: (1) recurrent urinary retention, (2) BPH-related macro-hematuria refractory to medical therapy with 5a-reductase inhibitors (5-ARI), (3) renal insufficiency or upper urinary tract dilatation, (4) bladder stones, and (5) recurrent urinary tract infection (UTI). The only contraindications for TURP are untreated UTI and bleeding disorders.

The inclusion criteria were age 45-85 years, IPSS ≥13, Q_max ≤15ml/s, post–voiding residual volume (PVR) of ≤300ml, and a prostate biopsy to confirm benign disease, when prostate specific antigen (PSA) was >2.5-4ng/mL despite of a 3 weeks antibiotic course. The standard protocol was used for the pre and postoperative examinations. Examinations of the patients before their operations included PSA, IPSS, Q_max, PVR, total prostate volume (TPV). Transrectal ultrasound (TRUS) was used for the total estimation of the prostate and its zones. TURP was performed using standard 24 French resectoscopes with a continued flow according to the technique of a complete adenoma resection, down to the surgical capsule.

In addition to routine examinations, following measures were taken for patients with different internal comorbidities before they underwent M-TURP: 1) controlling blood pressure within 140/90 mmHg in hypertensive patients; 2) maintaining fasting blood glucose at 6-8mmol and 2-h postprandial blood glucose below 11mmol/l; 3) improving and maintaining pulmonary or cardiac function in patients with chronic bronchitis, emphysema, or cardiac dysfunction; and 4) controlling blood pressure or treating anemia with active symptomatic treatment in patients with chronic renal insufficiency. Patients with deteriorating or unstable comorbidities were transferred to other departments for further treatment before being reconsidered for inclusion in the study. M-TURP system was used for treating patient’s (100 W for cutting and 50 W for coagulation; 1.5% Glycine as irrigation fluid). All the patients were placed in the lithotomy position and were given SA. The surgical procedures were performed based on the methodology described by Maurmayer. Bladder irrigation was initiated immediately after the patient was transferred to a ward or intensive care unit (ICU). Follow-up was arranged three, six and twelve months after TURP, and included IPSS, Q_max, TRUS and PVR investigations. The endpoint of the study was an evaluation of the treatment efficacy using pre/postoperative changes to IPSS and Q_max. The cut off of the efficacy of the operation was defined as 50% improvement of each evaluated parameter or decrease in IPSS (≥10 points), increase in Q_max (≥10ml/s). SPSS software version 13.0 was used for data analysis. Discrete and continuous variables were compared using chi-square test, student t test and post HOC test respectively and correlation coefficient was calculated using the Spearman R analysis. P values less than 0.05 were considered statistically significant. SPSS version 13 was used to evaluate all statistical analysis.

RESULTS

A total of 274 patients were divided into 3 groups based on prostate volume of less than 40 gram (Group A), 40 to 80 grams (Group B) and more than 80 grams (Group C). There were 2 patients in group A, 216 patients in the group B and 56 patients in the group C. All the patients underwent m-TURP with 1.5% Glycine as irrigation fluid under standard electrosurgical settings. Mean values of various biochemical and clinical parameters along with standard deviation has been shown in Figure 1 for all the patients together.

Mean age in the patient cohort was 64.64±8.23 years and mean prostate volume was 70.47±14.35gm. Age (Pearson’s R-0.71, p value 0.001) and prostate weight (Pearson’s R-0.383, p value 0.001) were significantly correlated with the patient population in both group B and C. Mean serum PSA for the entire patient population was 4.13±1.66ng/ml. Maximum number of patients with deranged plasma glucose were in group B (n=67, 31%). Statistically, deranged EFG was significantly associated and correlated with Group B. Altered waist to hip ratio was most evident in the group B as well (n=80, 37.04%) along with significant association and correlation. Dyslipidemia was evenly distributed in both group B (n=86, 39.8%) and C (n=19, 33.9%) along with significant statistical parameters as shown in Table 1. Hypertension was a very common phenomenon observed in both group B (n=78, 36.1%) and group C (n=22, 39.3%). Preoperative AUR marked its presence mostly in group B (n=49, 22.7%) confirming the previous literature that size was not the only significant criteria determining AUR. Post-operative AUR was vehemently related to the group B (n=22, 10.2%) as well along expected lines. Large prostate glands were related with increased risk of MI and were on regular anti coagulants for the same in group B (n=50, 23.1%).

Applying the Post Hoc test to ascertain the maximum variation among biochemical parameters in between the groups B and C signified that the serum PSA variation were maximum between the group B and C (Tukey HSD (I-J) - 1.31, p =0.001). The mean preoperative hemoglobin level for the entire patient population was 13.14±1.26 whereas the post-operative hemoglobin level was 12.22±1.39gm/dl. Similarly, the mean preoperative sodium level for the entire patient population was 137±4.26 whereas the post-operative level was 130±5.04mEq/L.

Significant hemoglobin (Tukey HSD (I-J) - 0.169, p = 0.003) and sodium (Tukey HSD (I-J) - 1.196, p = 0.007) drop in pre and post-operative scenarios were also seen between group B and C. On applying the one-way ANOVA hemoglobin drop was found to be significant when considering intergroup variation (F- 3.45, p= 0.033) but not when analyzing within the same group. The drop- in serum sodium concentration (F- 4.19, p= 0.016) was also found to be significant when analyzing the intergroup results than when observing the intra-group variation. Both sodium (Pearson’s R - 0.567, p = 0.001) and hemoglobin (Pearson’s R - 0.582, p = 0.003) variation were significantly correlated among the group B and C.

Post-surgery IPSS and maximum flow velocity showed expected improvement at 6 and 12 months and were maintained thereafter. All parameters were monitored routinely and any patient skipping the regular follow up was omitted from the statistical analysis. Mean PVRU for the group B was 187.45ml which dropped to an average of 50 cc at 6 months of the surgery and was statistically significant thus reinstating the belief in technique and the mode of treatment. Post-surgery Q_max also improved vitally improving the bothersome symptom of urgency and urgency incontinence which were evident by significant decrease in mean IPSS score. The maximum flow parameters were sustained at 12 months of follow up and patients showed stabilization of the same at further OPD visits. The classical TUR syndrome infamously associated with the m TURP technique was recorded in .08% (n= 27) patients. All patients recovered well on 3% NaCl 100ml i/v slow given over 4 hours till sodium correction after taking proper nephrology consultation. Urethral catheter was removed on an average on the 3^rd post-operative day (mean - 71.7 hours).

Urethral strictures were more common in the group B (n=22, 10.2%) followed by the group C (n=10, 17.9%). Mean resection time for the group B was 68.7±4.56 minutes (p= 0.76) and for group C was 77.45±3.12 minutes (p=0.12). Post-surgery hematuria within 3 months was mostly seen in large prostate gland and amounted to 14.96% of the cases with maximum cases occurring in group C and with infective pre-operative urine culture reports. Majority of the cases were managed conservatively on continuous irrigation but 36.58 % patients amongst the hematuria cohort required clot evacuation under anaesthesia. Sexual dysfunction rate was determined based on IIEF-5 validated questionnaire and sexual activity was advised at beginning of 3 months post-surgery. Majority patients had a prior history of some sort of sexual dysfunction before the surgery and were managed well on psychiatry consultation and medications.

DISCUSSION

Different surgical options are available for BPH, of which, monopolar transurethral resection of the prostate is the surgical gold standard for prostate volume less than 80ml.^5,6 A recent study analysed long term outcome of monopolar TURP done by single surgeon, including 3589 procedures. They reported that with technical advancement in TURP, stupendous success can be achieved with minimal complication rates.⁷ In one analysis, where 467 patients completed 5 years follow up, results of 177.8% increase in Q_max, 91.7% decrease in PVRU, 52.4% decrease in IPSS, 56.2% decrease in QoL and 42.8% decrease in overactive bladder symptom score compared to baseline were observed.⁸ Studies comparing monopolar and bipolar TURP reported similar and durable long term efficacy of either procedures.^9-12 Nonetheless, in one prospective study, where 36 patients finished 6 years follow up, authors concluded that Q_max and IPSS values were notably inferior to b-TURP compared to m-TURP (P<0.05).¹³ In a meta-analysis of 9 RCT’s, 448 and 441 patients underwent PVP and m-TURP respectively, where it was concluded that functional outcomes were similar in six studies, favoured m-TURP in two and PVP in one study. Nevertheless, overall intermediate term efficacy was similar with PVP and m-TURP.¹⁴ In the experience we concluded that the combined mean pre-surgical IPSS score for the group B and C was 30.29±2.52 which dropped down and stabilized at 9.48±1.05 at the end of 1 year follow up. The mean catheter time along with hospital time for the entire patient cohort was 2.88±0.88 days and 4.12±1.14 days respectively. Mean maximum flow rate (Q_max) at the end of 1 year follow up was 12.05±1.22ml/minute. The results and percentage change in the validated parameters were within comparable limits with that of the available published literature. The variation which did happen were mostly because not all surgeries were done by the faculty and resident training program was considered equally important but without compromising patient safety and surgical outcome.

Five RCT’s comparing HoLEP with m-TURP found equivalent improvements in IPSS, Q_max and PVR reported by Tan et al, Kuntz et al, Montorsi et al, Gupta et al, Mavuduru et al. A study reported superior urodynamic relief of bladder outlet obstruction for HoLEP at 6 months, whereas Montorsi and colleagues found no significant difference in urodynamic results at 12 months (Table 5). In an analysis of twenty RCTs reported between 2005 and 2009 and a follow-up of 60 months, m-TURP resulted in an improvement of the mean Q_max (162%), a reduction of the mean IPSS (-70%), and a reduction of mean PVR (-77%).¹⁵ One study reported a remarkable decrease in most symptoms and an improvement in the urodynamic variables after the mean period of 13 years, which demonstrated the efficacy of m-TURP in long-term settings. In general, the end result of TURP performed for LUTS is favourable in 78-93% of patients.^16-17

According to published and validated literature, the premier results for the management of LUTS were evinced after open prostatectomy when up to 97% of the prostate transition zone can be enucleated.¹⁸ The overall thrust of preoperative variables on management related functional outcome or treatment efficiency has been investigated in different prospective RCT’s. Symptom differentiation between LUTS due to neurogenic or myogenic causes related to bladder dysfunction and BPH is one of the essential points that can affect post-surgical performance. Nonetheless, recent results on TURP complications reported in the analysis of the contemporary RCT’s are not significantly higher in comparison to those observed with other techniques: bleeding requiring blood transfusion (2%), TUR syndrome (0.8%), acute urinary retention (4.5%), clot retention (4.9%), and UTI (4.1%).¹⁹ The duration of the surgery is currently much shorter (mean - 48.5 min), compared with an average of 57 and 62.5 min, respectively, in the past cohort reference studies.²⁰ However, taking into account the long term complications, studies reported different rates of urethral stricture, bladder neck contracture, residual adenoma requiring reoperation, UTI, dysuria, erectile dysfunction, retrograde ejaculation among others.²¹ Author observed similar rates of complications, including dysuria, UTI and urethral stricture among patients of the group B and C at 24 months follow up. At review, men who volunteered to undergo questions about their sexual life (n=66) were asked about their sexual function. Interestingly, 30% of men reported they were not sexually active and so did not finish the IIEF-5 questionnaire. Of the remaining 46 men who completed this questionnaire, the average score was 15. Unfortunately, no baseline record was available to allow postoperative changes to be calculated. This result can be equated with the general population. Many studies have reported that up to 80% of men over 70 years of age have a degree of sexual impairment.^22-24 While we accept that the data in this series is restricted, it does suggest that m-TURP has had no long-term consequence on erectile function. It does, nevertheless, have a noteworthy impact on antegrade emission. Nearly eighty percent (n=52) of sexually active men revealed loss of emission on orgasm at follow up visits.

CONCLUSION

Monopolar TURP is still alive and evolving as an effective and foremost weapon in the hands of young urologist in 2017, despite Stamey’s affirmation in 1993 that “TURP is now a therapy of history. TURP has taken on many challenges, but still remains the gold standard to which others are compared. M-TURP is adequate for its intended use as an effective learning tool and as a substantial practical tool for managing BPH; m-TURP results depend on surgeons’ experience, the patient’s prostate volume- and comorbidities. Therefore, in appropriately selected patients TURP has an unrivalled tract record of durability and endurance. M-TURP is one of the first endoscopic procedures that urology residents deliver and is also one of the bread-and-butter operations most urologists perform. The setup is available in almost all hospitals. In our personal experience we would like to conclude that before conquering the unheralded heights of ever changing newer modalities in surgical treatment of BPH, a budding urologist should learn to scale and master each and every trick of m-TURP to achieve maximum success for his patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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